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Introduction - Diametrically aberrant mentalising biases, namely hypermentalising in psychosis and hypomentalising in autism, are postulated by some theoretical models. To test this hypothesis, we measured psychotic-like experiences, autistic traits and mentalising biases in a visual chasing paradigm. Methods - Participants from the general population (N = 300) and psychotic patients (N=26) judged the absence or presence of a chase during five-second long displays of seemingly randomly moving dots. Hypermentalising is seeing a chase where there is none, whereas hypomentalising is missing to see a chase. Results - Psychotic-like experiences were associated with hypermentalising. Autistic traits were not associated with hypomentalising, but with a reduced ability to discriminate chasing from non-chasing trials. Given the high correlation (τ = .41) between autistic traits and psychotic-like experiences, we controlled for concomitant symptom severity on agency detection. We found that all but those with many autistic and psychotic traits showed hypomentalising, suggesting an additive effect of traits on mentalising. In the second study, we found no hypermentalising in patients with psychosis, who performed also similarly to a matched control group. Conclusions - The results suggest that hypermentalising is a cognitive bias restricted to subclinical psychotic-like experiences. There was no support for a diametrically opposite mentalising bias along the autism-psychosis continuum.

China aktuell, China aktuell - Oktober 1998

Social cognition (SC) impairments in schizophrenia predict interpersonal problems and low functional outcome, which might be aggravated by low (meta-) cognitive awareness of individual symptoms and cognitive biases. Metacognitive Training (MCT) aims to raise patients' awareness of cognitive biases, for example overconfidence in errors. We examined whether MCT reduces high-confident false mental state perceptions and tried to identify possible underlying mechanisms of SC impairments. A total of 150 patients were enrolled in a randomized clinical trial comparing the MCT with cognitive remediation (CogPack®) as the active control. Participants were assessed at baseline and at four weeks (post) and further six months (follow-up) later with the Reading the Eyes in the Mind-test also measuring the patients' response confidence. We found that compared to CogPack® MCT reliably reduced the amount of overconfident SC errors by approximately 40% at follow-up. Additionally, we were able to link several symptomatic features and neuropsychological parameters to SC impairments and overconfidence herein.

Background Theory-driven interventions targeting specific factors that contribute to delusions are receiving increased interest. The present study aimed to assess the efficacy of individualized metacognitive therapy (MCT+), a short manualized intervention that addresses delusion-associated cognitive biases. Methods 92 patients with current or past delusions were randomized to receive 12 twice-weekly sessions of either MCT+ or a control intervention within a randomized controlled rater-blind design. Psychopathology and cognitive biases were assessed at baseline, 6 weeks and 6 months. ANCOVAs adjusted for baseline scores were used to assess differences between groups regarding outcome variables. Both per-protocol and intention-to-treat analyses were conducted. Results At 6 weeks, there was a significant difference in favor of MCT+ regarding decrease in delusion severity and improvement of self-reflectiveness (medium effect size), and a trend-wise difference regarding probability thresholds to decision. These effects increased, when only patients attending a minimum of 4 therapy sessions were considered. Control group patients subsequently showed further improvement while patients in the MCT+ group remained stable, such that there were no differences between groups at the 6-month follow-up. Limitations Lower attendance rates in the control group possibly leading to unequal therapeutic effort; lower baseline delusion severity in the MCT+ group. Conclusions The result pattern suggests that MCT+ led to earlier improvement in delusions and cognitive biases compared to the control intervention. The absence of a long-term effect might reflect floor effects in the MCT+ group, but may also indicate the need for further measures to promote sustainability of MCT+ effects.

Eine psychologische, verstandnisbasierte Auseinandersetzung mit Wahn und Schizophrenie hat erst in jungster Zeit an wissenschaftlicher Akzeptanz und klinischem Einfluss gewonnen. Fur diese verzogerte Entwicklung scheint, wie bereits erwahnt, ein historischer Vorbehalt bezuglich der Durchfuhrbarkeit und des Erfolgs psychotherapeutischer Masnahmen bei psychotischen Storungen seitens der grosen psychotherapeutischen Schulen, der Psychoanalyse und teilweise auch der Verhaltenstherapie, verantwortlich zu sein. Unter dem Jaspers'schen Postulat der Unverstehbarkeit von Psychosen und Freuds Annahme der fehlenden Gegenubertragung galten Schizophrenie und Wahn lange Zeit auch unter Psychologen als rein biologisch begrundet und damit als »Sache des Arztes bzw. Apothekers«. Diese Vorstellungen sind nicht zuletzt durch zahlreiche Befunde der Grundlagenforschung und erfolgreiche verhaltenstherapeutische Ansatze korrigiert worden.

Background: Phenomenological descriptions of psychosis traditionally emphasize the subjective burden that psychosis inflicts on patients. However, a growing body of work suggests that in a subgroup of patients, psychotic symptoms are appraised as positive. The present study set out to explore the frequency of positive, negative and ambivalent attitudes towards positive symptoms. We were also interested in characterizing the phenomenological structure of positive symptoms.Method: Participants were recruited over the Internet via specialized psychosis forums. Among other questionnaires, participants completed the Community Assessment of Psychic Experiences (CAPE) scale. In addition, we administered a novel scale called Subjective Perception of Positive Symptoms (SUPPOSY) that assesses core positive symptoms along various dimensions (e.g. emotional appraisal, impact on daily life).Results: For all symptom clusters, the majority of participants expressed ambivalence. Psychotic symptoms were associated with bo...

Background Symptom reduction under antipsychotic agents is incomplete for most schizophrenia patients. In order to enhance outcome, cognitive approaches are increasingly adopted as add-on interventions. The present study aimed to determine the efficacy of group Metacognitive Training (MCT), which targets cognitive biases putatively involved in the pathogenesis of delusions. Methods A two-center, randomized, assessor-blind, controlled trial between MCT group training and cognitive training was carried out (ISRCTN95205723). A total of 150 in- and outpatients with DSM diagnoses of schizophrenia spectrum disorders were enrolled. All patients were concurrently prescribed antipsychotic medication. Assessments were made at baseline, four weeks and six months later. The primary outcome was a delusion score derived from the Positive and Negative Syndrome Scale (PANSS). The Psychotic Symptom Rating Scales (PSYRATS) as well as cognitive measures served as secondary outcomes. Results Completion at follow-up was 86%. According to intention-to-treat (ITT) analyses, patients in the MCT group showed significantly greater symptom reduction on the PANSS delusion subscore (follow-up), PANSS positive score (post-treatment) and PSYRATS delusion score (post-treatment and follow-up). Improvement on the PANSS positive scale at post-treatment and follow-up was positively correlated with the number of attended MCT sessions. No changes were seen for other psychopathological syndromes. Discussion MCT, a low-intensity training aimed at enhancing patients' awareness of cognitive biases subserving paranoia, led to improvement in delusion symptoms relative to the control condition and over and above the effects of antipsychotic medication. This improvement was sustained at follow-up.

Background: Metacognitive Group Training for Schizophrenia Patients (MCTg) focuses on dysfunctional thinking styles (e.g. cognitive biases) putatively involved in the formation and maintenance of delusions. Recently, the Individualized Metacognitive Therapy Program for Patients with Psychosis (MCT+), an extension of the group training, was released. MCT+ sessions aim to correct false metacognitive beliefs, which in turn should challenge a patient's personal delusional convictions. Aims: The present study demonstrates how MCT and MCT+ can be combined and how the contents are conveyed to the patient. Method: We present a single case study of a patient undergoing a combined treatment of MCT and MCT+. Before intervention and 4 weeks later the Positive and Negative Syndrome Scale (PANSS) and the Psychotic Symptom Rating Scales (PSYRATS) were administered. Results: The patient showed a substantial symptom reduction after 4 weeks of combined therapy of MCTg and MCT+ as measured with PANSS and PSYRATS. Conclusions: The present case history lends preliminary evidence for the feasibility of this new treatment approach in psychosis.

Prior studies have confirmed a bias against disconfirmatory evidence (BADE) in schizophrenia which has been associated with delusions. However, its role in the pathogenesis of psychosis is yet unclear. The objective was to investigate BADE for the first time in subjects with an at-risk-mental-state for psychosis (ARMS), patients with a first episode of psychosis without antipsychotic treatment (FEP) and healthy controls (HC). A standard BADE test presenting written scenarios was employed. In addition, psychometric rating scales and a neuropsychological test battery were applied. A three-staged image was revealed. FEP-patients showed a significant BADE compared to the other groups. The performance of ARMS-patients lay in between HC and FEP-patients. A trend towards significance became evident for a bias against confirmatory evidence (BACE) in FEP-patients. Results were not attributable to antipsychotic or other medication or depressive symptoms. Correlations with delusions reached medium effect sizes but failed significance after Bonferroni-corrections. These results provide evidence for aberrations in evidence integration in the pathogenesis of psychosis and contribute to our knowledge of metacognitive functioning which can be used for (meta-)cognitive intervention in psychosis. published

Antipsychotic medication represents the treatment of choice in psychosis according to clinical guidelines. Nevertheless, studies show that half to almost three-quarter of all patients discontinue medication with antipsychotics after some time, a fact which is traditionally ascribed to side-effects, mistrust against the clinician and poor illness insight. The present study investigated whether positive attitudes toward psychotic symptoms (ie, gain from illness) represent a further factor for medication noncompliance. An anonymous online survey was set up in order to prevent conservative response biases that likely emerge in a clinical setting. Following an iterative selection process, data from a total of 113 patients with a likely diagnosis of schizophrenia and a history of antipsychotic treatment were retained for the final analyses (80%). While side-effect profile and mistrust emerged as the most frequent reasons for drug discontinuation, 28% of the sample reported gain from illness (eg, missing voices, feeling of power) as a motive for noncompliance. At least every fourth patient reported the following reasons: stigma (31%), mistrust against the physician/therapist (31%), and rejection of medication in general (28%). Approximately every fifth patient had discontinued antipsychotic treatment because of forgetfulness. On average, patients provided 4 different explanations for noncompliance. Ambivalence toward symptoms and treatment should thoroughly be considered when planning treatment in psychosis. While antipsychotic medication represents the evidence-based cornerstone of the current treatment in schizophrenia, further research is needed on nonpharmacological interventions for noncompliant patients who are willing to undergo intervention but refuse pharmacotherapy.

Metacognitive training (MCT) for patients with schizophrenia is a novel psychological group treatment targeting cognitive biases putatively involved in the pathogenesis of schizophrenia (e.g. jumping to conclusions, overconfidence in errors). Its eight modules are available cost-free online in many languages. In the present study, 36 subacute or remitted patients were randomly allocated to either the MCT or a wait-list group who received treatment-as-usual (TAU). Baseline and post assessments were 8 weeks apart and were performed blind to group status. MCT showed significantly greater improvement on the following parameters relative to the TAU group: delusion distress (PSYRATS), memory and social quality of life. In the MCT group, the rate of jumping to conclusions bias was reduced after training. No differences occurred on the PANSS. The present study confirms prior reports that MCT exerts beneficial effects on some cognitive and symptomatic parameters.

Background: Opposing predictions have been formulated with regard to the causal relationship between paranoia and self‐esteem, either assuming a protective role of paranoia for explicit self‐esteem or a linear decrease of self‐esteem upon symptom deterioration. The primary purpose of the present study was to provide estimates for the prevalence of low self‐esteem in people diagnosed with schizophrenia during psychiatric treatment. Method: Self‐esteem was assessed in a cohort of 58 schizophrenia patients at the beginning of psychiatric treatment and 44 healthy controls. A subgroup of 45 patients and 24 controls was reassessed 4 weeks later. Results: At baseline, 42% of the patients displayed low self‐esteem (i.e. one standard deviation below the norm; re‐assessment: 49%). Baseline depression and antipsychotic dosage were the strongest predictors for low self‐esteem after 4 weeks. While paranoid ideas were not related to self‐esteem, neither cross‐sectionally nor longitudinally, grandiose delusions were mod...

BackgroundCognitive biases, especially jumping to conclusions (JTC), are ascribed a vital role in the pathogenesis of schizophrenia. This study set out to explore motivational factors for JTC using a newly developed paradigm.MethodTwenty-seven schizophrenia patients and 32 healthy controls were shown 15 classical paintings, divided into three blocks. Four alternative titles (one correct and three lure titles) had to be appraised according to plausibility (0–10). Optionally, participants could decide for one option and reject one or more alternatives. In random order across blocks, anxiety-evoking music, happy music or no music was played in the background.ResultsPatients with schizophrenia, particularly those with delusions, made more decisions than healthy subjects. In line with the liberal acceptance (LA) account of schizophrenia, the decision threshold was significantly lowered in patients relative to controls. Patients were also more prone than healthy controls to making a decision when the distance between the first and second best alternative was close. Furthermore, implausible alternatives were judged as significantly more plausible by patients. Anxiety-evoking music resulted in more decisions in currently deluded patients relative to non-deluded patients and healthy controls.ConclusionsThe results confirm predictions derived from the LA account and assert that schizophrenia patients decide hastily under conditions of continued uncertainty. The fact that mood induction did not exert an overall effect could be due to the explicit nature of the manipulation, which might have evoked strategies to counteract their influence.

Prior studies with schizophrenia patients described a reduced ability to discriminate between correct and false memories in terms of confidence compared to control groups. This metamemory bias has been associated with the emergence and maintenance of delusions. The relation to neuropsychological performance and other clinical dimensions is incompletely understood. In a cross-sectional study, metamemory functioning was explored in 32 schizophrenia patients and 25 healthy controls. Metamemory was assessed using a verbal recognition task combined with retrospective confidence level ratings. Associations of metamemory performance with six neuropsychological domains (executive functioning/problem solving, speed of processing, working memory, verbal and visual learning, and attention/vigilance) and psychopathological measures were analyzed. Results revealed a significantly smaller discrepancy between confidence ratings for correct and incorrect recognitions in the patient group. Furthermore, patients showed significantly lower recognition accuracy in the metamemory task and marked deficits in all neuropsychological domains. Across all participants, metamemory performance significantly correlated with executive functioning and working memory. No associations with delusions were found. This data confirms prior findings of metamemory biases in schizophrenia. Selective neuropsychological abilities seem to be modulating factors of metamemory functioning. Longitudinal studies in at risk mental state and first-episode patients are needed to reveal causal interrelations. published

BackgroundMetamemory describes the monitoring and knowledge about one's memory capabilities. Patients with schizophrenia have been found to be less able in differentiating between correct and false answers (smaller confidence gap) when asked to provide retrospective confidence ratings in previous studies. Furthermore, higher proportions of very-high-confident but false responses have been found in this patient group (high knowledge corruption). Whether and how these biases contribute to the early pathogenesis of psychosis is yet unclear. This study thus aimed at investigating metamemory function in the early course of psychosis.MethodPatients in an at-risk mental state for psychosis (ARMS, n = 34), patients with a first episode of psychosis (FEP, n = 21) and healthy controls (HCs, n = 38) were compared on a verbal recognition task combined with retrospective confidence-level ratings.ResultsFEP patients showed the smallest confidence gap, followed by ARMS patients, followed by HCs. All groups differed significantly from each other. Regarding knowledge corruption, FEP patients differed significantly from HCs, whereas a statistical trend was revealed in comparison of ARMS and FEP groups. Correlations were revealed between metamemory, measures of positive symptoms and working memory performance.ConclusionsThese data underline the presence of a metamemory bias in ARMS patients which is even more pronounced in FEP patients. The bias might represent an early cognitive marker of the beginning psychotic state. Longitudinal studies are needed to unravel whether metacognitive deficits predict the transition to psychosis and to evaluate therapeutic interventions.

Previous studies have demonstrated a cognitive bias in the integration of disconfirmatory evidence (BADE) in patients with schizophrenia. This bias has been associated with delusions. So far, it is unclear how the integration of evidence is associated with neurocognitive capabilities. In the current study, 31 patients with schizophrenia and 29 healthy controls, matched on age, gender, education and premorbid verbal intelligence, underwent a BADE task. Written scenarios of three consecutive sentences each were presented, which progressively reduced the ambiguity of situations. Participants were asked to rate the plausibility of four possible interpretations and adjust their ratings in response to the provided sentences. Psychometric rating scales and a neuropsychological test battery were applied. Patients displayed a bias in the integration of confirmatory, but not disconfirmatory evidence and a liberal acceptance of belief formation. Correlation analyses revealed no associations of evidence integration with the severity of positive symptoms, but with neurocognitive domains, especially with processing speed, executive functioning, vigilance and working memory. In conclusion, patients with schizophrenia show a bias in evidence integration. Neurocognitive functioning emerged as a modulatory factor that should be considered in further research. Studies investigating BADE in earlier stages of psychosis will be necessary to reveal causal relationships.

Background and objectives There is emerging evidence that the induction of doubt can reduce positive symptoms in patients with schizophrenia. Based on prior investigations indicating that brief psychological interventions may attenuate core aspects of delusions, we set up a proof of concept study using a virtual reality experiment. We explored whether feedback for false judgments positively influences delusion severity. Methods A total of 33 patients with schizophrenia participated in the experiment. Following a short practice trial, patients were instructed to navigate through a virtual street on two occasions (noise versus no noise), where they met six different pedestrians in each condition. Subsequently, patients were asked to recollect the pedestrians and their corresponding facial affect in a recognition task graded for confidence. Before and after the experiment, the Paranoia Checklist (frequency subscale) was administered. Results The Paranoia Checklist score declined significantly from pre to post at a medium effect size. We split the sample into those with some improvement versus those that either showed no improvement, or worsened. Improvement was associated with lower confidence ratings (both during the experiment, particularly for incorrect responses, and according to retrospect assessment). Limitations No control condition, unclear if improvement is sustained. Discussion The study tentatively suggests that a brief virtual reality experiment involving error feedback may ameliorate delusional ideas. Randomized controlled trials and dismantling studies are now needed to substantiate the findings and to pinpoint the underlying therapeutic mechanisms, for example error feedback or fostering attenuation of confidence judgments in the face of incomplete evidence.